Radiology Coding Alert

Question: What CPT Code should we report if the radiologist performs a pelvic ultrasound on a patient with pelvic pain and discovers that the patient is pregnant?


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Answer: If the patient presents with pelvic pain but without a confirmed diagnosis of pregnancy, you should base your CPT choice on the reason for the exam. In this case, report 76856 (Ultrasound, pelvic [nonobstetric], B-scan and/or real time with image documentation; complete).

Remember: To report 76856, you need a complete evaluation of the pelvic anatomy. For the female patient, this includes a description and measurement of the endometrium, measurement of the bladder (when applicable), and a description of any pelvic pathology.

If the patient presents as being pregnant (confirmed with a positive pregnancy test), it is an ob ultrasound (76801-76817), regardless of findings.

The answers for You Be the Coder and Reader Questions were reviewed by Jackie Miller, RHIA, CPC, senior consultant with Coding Strategies Inc. in Powder Springs, Ga.; and Gary S. Dorfman, MD, FACR, FSIR.